UPGRADED HESI
FUNDAMENTALS ACTUAL
EXAM QUESTIONS AND
ANSWERS
An54elderly54client54with54a54fractured54left54hip54is54on54strict54bedrest.54Which54nursing54measure54i
s54essential54to54the54client's54nursing54care?
A. Massage54any54reddened54areas54for54at54least54five54minutes.
B. Encourage54active54range54of54motion54exercises54on54extremities.
C. Position54the54client54laterally,54prone,54and54dorsally54in54sequence.
D. Gently54lift54the54client54when54moving54into54a54desired54position.54-54CORRECT54ANSWER54-
To54avoid54shearing54forces54when54repositioning,54the54client54should54be54lifted54gently54across54a54
surface54(D).54Reddened54areas54should54not54be54massaged54(A)54since54this54may54increase54the54d
amage54to54already54traumatized54skin.54To54control54pain54and54muscle54spasms,54active54range54of5
4motion54(B)54may54be54limited54on54the54affected54leg.54The54position54described54in54(C)54is54contra
indicated54for54a54client54with54a54fractured54left54hip.
Correct54Answer:54D
The54nurse54is54administering54medications54through54a54nasogastric54tube54(NGT)54which54is54connec
ted54to54suction.54After54ensuring54correct54tube54placement,54what54action54should54the54nurse54tak
e54next?
A. Clamp54the54tube54for542054minutes.
B. Flush54the54tube54with54water.
C. Administer54the54medications54as54prescribed.
D. Crush54the54tablets54and54dissolve54in54sterile54water.54-54CORRECT54ANSWER54-
The54NGT54should54be54flushed54before,54after54and54in54between54each54medication54administered5
4(B).54Once54all54medications54are54administered,54the54NGT54should54be54clamped54for542054minutes
54(A).54(C54and54D)54may54be54implemented54only54after54the54tubing54has54been54flushed.
,Correct54Answer:54B
A54client54who54is54in54hospice54care54complains54of54increasing54amounts54of54pain.54The54healthcar
e54provider54prescribes54an54analgesic54every54four54hours54as54needed.54Which54action54should54the
54nurse54implement?
A. Give54an54around-the-clock54schedule54for54administration54of54analgesics.
B. Administer54analgesic54medication54as54needed54when54the54pain54is54severe.
C. Provide54medication54to54keep54the54client54sedated54and54unaware54of54stimuli.
D. Offer54a54medication-free54period54so54that54the54client54can54do54daily54activities.54-
54CORRECT54ANSWER54-
The54most54effective54management54of54pain54is54achieved54using54an54around-the-
clock54schedule54that54provides54analgesic54medications54on54a54regular54basis54(A)54and54in54a54timel
y54manner.54Analgesics54are54less54effective54if54pain54persists54until54it54is54severe,54so54an54analgesi
c54medication54should54be54administered54before54the54client's54pain54peaks54(B).54Providing54comfort
54is54a54priority54for54the54client54who54is54dying,54but54sedation54that54impairs54the54client's54ability54
to54interact54and54experience54the54time54before54life54ends54should54be54minimized54(C).54Offering54
a54medication-
free54period54allows54the54serum54drug54level54to54fall,54which54is54not54an54effective54method54to54
manage54chronic54pain54(D).
Correct54Answer:54A
When54assessing54a54client54with54wrist54restraints,54the54nurse54observes54that54the54fingers54on54th
e54right54hand54are54blue.54What54action54should54the54nurse54implement54first?
A. Loosen54the54right54wrist54restraint.
B. Apply54a54pulse54oximeter54to54the54right54hand.
C. Compare54hand54color54bilaterally.
D. Palpate54the54right54radial54pulse.54-54CORRECT54ANSWER54-
The54priority54nursing54action54is54to54restore54circulation54by54loosening54the54restraint54(A),54becaus
e54blue54fingers54(cyanosis)54indicates54decreased54circulation.54(C54and54D)54are54also54important54n
ursing54interventions,54but54do54not54have54the54priority54of54(A).54Pulse54oximetry54(B)54measures54t
he54saturation54of54hemoglobin54with54oxygen54and54is54not54indicated54in54situations54where54the54
cyanosis54is54related54to54mechanical54compression54(the54restraints).
Correct54Answer:54A
The54nurse54is54assessing54the54nutritional54status54of54several54clients.54Which54client54has54the54gre
,atest54nutritional54need54for54additional54intake54of54protein?
A. A54college-age54track54runner54with54a54sprained54ankle.
, B. A54lactating54woman54nursing54her543-day-old54infant.
C. A54school-aged54child54with54Type54254diabetes.
D. An54elderly54man54being54treated54for54a54peptic54ulcer.54-54CORRECT54ANSWER54-
A54lactating54woman54(B)54has54the54greatest54need54for54additional54protein54intake.54(A,54C,54and5
4D)54are54all54conditions54that54require54protein,54but54do54not54have54the54increased54metabolic54
protein54demands54of54lactation.
Correct54Answer:54B
A54client54is54in54the54radiology54department54at54090054when54the54prescription54levofloxacin54(Leva
quin)5450054mg54IV54q24h54is54scheduled54to54be54administered.54The54client54returns54to54the54unit54
at541300.54What54is54the54best54intervention54for54the54nurse54to54implement?
A. Contact54the54healthcare54provider54and54complete54a54medication54variance54form.
B. Administer54the54Levaquin54at54130054and54resume54the54090054schedule54in54the54morning.
C. Notify54the54charge54nurse54and54complete54an54incident54report54to54explain54the54missed54dose.
D. Give54the54missed54dose54at54130054and54change54the54schedule54to54administer54daily54at541300
.54-54CORRECT54ANSWER54-
To54ensure54that54a54therapeutic54level54of54medication54is54maintained,54the54nurse54should54admi
nister54the54missed54dose54as54soon54as54possible,54and54revise54the54administration54schedule54acc
ordingly54to54prevent54dangerously54increasing54the54level54of54the54medication54in54the54bloodstrea
m54(D).54The54nurse54should54document54the54reason54for54the54late54dose,54but54(A54and54C)54are54
not54warranted.54(B)54could54result54in54increased54blood54levels54of54the54drug.
Correct54Answer:54D
While54instructing54a54male54client's54wife54in54the54performance54of54passive54range-of-
motion54exercises54to54his54contracted54shoulder,54the54nurse54observes54that54she54is54holding54his54arm5
4above54and54below54the54elbow.54What54nursing54action54should54the54nurse54implement?
A. Acknowledge54that54she54is54supporting54the54arm54correctly.
B. Encourage54her54to54keep54the54joint54covered54to54maintain54warmth.
C. Reinforce54the54need54to54grip54directly54under54the54joint54for54better54support.
D. Instruct54her54to54grip54directly54over54the54joint54for54better54motion.54-54CORRECT54ANSWER54-
The54wife54is54performing54the54passive54ROM54correctly,54therefore54the54nurse54should54acknowle
dge54this54fact54(A).54The54joint54that54is54being54exercised54should54be54uncovered54(B)54while54the
54rest54of54the54body54should54remain54covered54for
FUNDAMENTALS ACTUAL
EXAM QUESTIONS AND
ANSWERS
An54elderly54client54with54a54fractured54left54hip54is54on54strict54bedrest.54Which54nursing54measure54i
s54essential54to54the54client's54nursing54care?
A. Massage54any54reddened54areas54for54at54least54five54minutes.
B. Encourage54active54range54of54motion54exercises54on54extremities.
C. Position54the54client54laterally,54prone,54and54dorsally54in54sequence.
D. Gently54lift54the54client54when54moving54into54a54desired54position.54-54CORRECT54ANSWER54-
To54avoid54shearing54forces54when54repositioning,54the54client54should54be54lifted54gently54across54a54
surface54(D).54Reddened54areas54should54not54be54massaged54(A)54since54this54may54increase54the54d
amage54to54already54traumatized54skin.54To54control54pain54and54muscle54spasms,54active54range54of5
4motion54(B)54may54be54limited54on54the54affected54leg.54The54position54described54in54(C)54is54contra
indicated54for54a54client54with54a54fractured54left54hip.
Correct54Answer:54D
The54nurse54is54administering54medications54through54a54nasogastric54tube54(NGT)54which54is54connec
ted54to54suction.54After54ensuring54correct54tube54placement,54what54action54should54the54nurse54tak
e54next?
A. Clamp54the54tube54for542054minutes.
B. Flush54the54tube54with54water.
C. Administer54the54medications54as54prescribed.
D. Crush54the54tablets54and54dissolve54in54sterile54water.54-54CORRECT54ANSWER54-
The54NGT54should54be54flushed54before,54after54and54in54between54each54medication54administered5
4(B).54Once54all54medications54are54administered,54the54NGT54should54be54clamped54for542054minutes
54(A).54(C54and54D)54may54be54implemented54only54after54the54tubing54has54been54flushed.
,Correct54Answer:54B
A54client54who54is54in54hospice54care54complains54of54increasing54amounts54of54pain.54The54healthcar
e54provider54prescribes54an54analgesic54every54four54hours54as54needed.54Which54action54should54the
54nurse54implement?
A. Give54an54around-the-clock54schedule54for54administration54of54analgesics.
B. Administer54analgesic54medication54as54needed54when54the54pain54is54severe.
C. Provide54medication54to54keep54the54client54sedated54and54unaware54of54stimuli.
D. Offer54a54medication-free54period54so54that54the54client54can54do54daily54activities.54-
54CORRECT54ANSWER54-
The54most54effective54management54of54pain54is54achieved54using54an54around-the-
clock54schedule54that54provides54analgesic54medications54on54a54regular54basis54(A)54and54in54a54timel
y54manner.54Analgesics54are54less54effective54if54pain54persists54until54it54is54severe,54so54an54analgesi
c54medication54should54be54administered54before54the54client's54pain54peaks54(B).54Providing54comfort
54is54a54priority54for54the54client54who54is54dying,54but54sedation54that54impairs54the54client's54ability54
to54interact54and54experience54the54time54before54life54ends54should54be54minimized54(C).54Offering54
a54medication-
free54period54allows54the54serum54drug54level54to54fall,54which54is54not54an54effective54method54to54
manage54chronic54pain54(D).
Correct54Answer:54A
When54assessing54a54client54with54wrist54restraints,54the54nurse54observes54that54the54fingers54on54th
e54right54hand54are54blue.54What54action54should54the54nurse54implement54first?
A. Loosen54the54right54wrist54restraint.
B. Apply54a54pulse54oximeter54to54the54right54hand.
C. Compare54hand54color54bilaterally.
D. Palpate54the54right54radial54pulse.54-54CORRECT54ANSWER54-
The54priority54nursing54action54is54to54restore54circulation54by54loosening54the54restraint54(A),54becaus
e54blue54fingers54(cyanosis)54indicates54decreased54circulation.54(C54and54D)54are54also54important54n
ursing54interventions,54but54do54not54have54the54priority54of54(A).54Pulse54oximetry54(B)54measures54t
he54saturation54of54hemoglobin54with54oxygen54and54is54not54indicated54in54situations54where54the54
cyanosis54is54related54to54mechanical54compression54(the54restraints).
Correct54Answer:54A
The54nurse54is54assessing54the54nutritional54status54of54several54clients.54Which54client54has54the54gre
,atest54nutritional54need54for54additional54intake54of54protein?
A. A54college-age54track54runner54with54a54sprained54ankle.
, B. A54lactating54woman54nursing54her543-day-old54infant.
C. A54school-aged54child54with54Type54254diabetes.
D. An54elderly54man54being54treated54for54a54peptic54ulcer.54-54CORRECT54ANSWER54-
A54lactating54woman54(B)54has54the54greatest54need54for54additional54protein54intake.54(A,54C,54and5
4D)54are54all54conditions54that54require54protein,54but54do54not54have54the54increased54metabolic54
protein54demands54of54lactation.
Correct54Answer:54B
A54client54is54in54the54radiology54department54at54090054when54the54prescription54levofloxacin54(Leva
quin)5450054mg54IV54q24h54is54scheduled54to54be54administered.54The54client54returns54to54the54unit54
at541300.54What54is54the54best54intervention54for54the54nurse54to54implement?
A. Contact54the54healthcare54provider54and54complete54a54medication54variance54form.
B. Administer54the54Levaquin54at54130054and54resume54the54090054schedule54in54the54morning.
C. Notify54the54charge54nurse54and54complete54an54incident54report54to54explain54the54missed54dose.
D. Give54the54missed54dose54at54130054and54change54the54schedule54to54administer54daily54at541300
.54-54CORRECT54ANSWER54-
To54ensure54that54a54therapeutic54level54of54medication54is54maintained,54the54nurse54should54admi
nister54the54missed54dose54as54soon54as54possible,54and54revise54the54administration54schedule54acc
ordingly54to54prevent54dangerously54increasing54the54level54of54the54medication54in54the54bloodstrea
m54(D).54The54nurse54should54document54the54reason54for54the54late54dose,54but54(A54and54C)54are54
not54warranted.54(B)54could54result54in54increased54blood54levels54of54the54drug.
Correct54Answer:54D
While54instructing54a54male54client's54wife54in54the54performance54of54passive54range-of-
motion54exercises54to54his54contracted54shoulder,54the54nurse54observes54that54she54is54holding54his54arm5
4above54and54below54the54elbow.54What54nursing54action54should54the54nurse54implement?
A. Acknowledge54that54she54is54supporting54the54arm54correctly.
B. Encourage54her54to54keep54the54joint54covered54to54maintain54warmth.
C. Reinforce54the54need54to54grip54directly54under54the54joint54for54better54support.
D. Instruct54her54to54grip54directly54over54the54joint54for54better54motion.54-54CORRECT54ANSWER54-
The54wife54is54performing54the54passive54ROM54correctly,54therefore54the54nurse54should54acknowle
dge54this54fact54(A).54The54joint54that54is54being54exercised54should54be54uncovered54(B)54while54the
54rest54of54the54body54should54remain54covered54for
